Inspection on 11/10/06 for Victoria House

This inspection was carried out on 11th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Victoria House 03/03/09

Victoria House 13/12/07

Victoria House 10/08/07

Victoria House 24/11/05

Victoria House 23/06/05

Victoria House 11/11/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE 77 Victoria Road Care Home 77 Victoria Road Rushden Northants NN10 0SA Lead Inspector Mrs Linda Preen Unannounced Inspection 11th October 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 77 Victoria Road Care Home DS0000060005.V316056.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 77 Victoria Road Care Home DS0000060005.V316056.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 77 Victoria Road Care Home Address 77 Victoria Road Rushden Northants NN10 0SA Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01933 417950 01933 417951 www.shaw.co.uk Shaw Healthcare (de Montfort) Ltd Mrs Susan Anne Attley Care Home 45 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (45), of places Physical disability over 65 years of age (6) 77 Victoria Road Care Home DS0000060005.V316056.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. All re-development work detailed in the refurbishment plan submitted to the Commission on 25.04.04 must be completed by March 2009. The home may continue to accommodate 2 named service users who fall within the registration category MD (E) No one falling within the category of DE (E) may be admitted into the home where there are 8 service users who fall within the category of DE (E) already accommodated within the home No one falling within the category of PD (E) may be admitted into the home where there are 6 service users who fall within the category of PD (E) already accommodated within the home A total of 45 in the category of old age, not falling within any other category (OP) A total of 6 in the category of mental illness over 65 years of age MD (E) Maximum number of service users is 45 4. 5. 6. 7. Date of last inspection 24th November 2005 Brief Description of the Service: 77 Victoria Road is a residential care home currently owned by Shaw Healthcare. The home provides care for up to 45 Service Users over the age of 65 years. Within the homes total of 45 Service User up to 8 older people with dementia and up to 6 people with physical disabilities can be provided with personal care. The Home is situated within walking distance of Rushden town centre, has extensive gardens and all facilities are located on the ground floor. Service Users have easy access to local facilities and amenities. All bedrooms are single occupancy rooms with easily accessible communal areas. The home is made up of several smaller units, each with their own lounge, dining area and kitchenette as well as a central larger lounge and bar area. 77 Victoria Road Care Home DS0000060005.V316056.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two hours were spent prior to the inspection reviewing previous requirements and recommendations and collating information provided by the service. The Commission sent comment cards out to a random selection of residents and to General Practices providing a service to the home. The inspection took place over a period of six 2ours as part of the statutory inspection programme. Four residents were chosen in order that their experience in the home could be assessed. The method used was “Case Tracking”. This involved looking at their records, talking to them and also to the staff concerning the care received. In addition to this staff rotas and medication records were seen. 3 comment cards had been received from residents, 1 comment cards from a General Practitioner, and information was available from a questionnaire completed by the providers of the service. Fees range from £444.83 to £486.23 according to resident’s assessed needs. What the service does well: What has improved since the last inspection? Some new carpets have been provided in communal areas and a continuing programme of redecoration is in progress to keep the home up to standard while waiting for the total refurbishment planned for next year. 77 Victoria Road Care Home DS0000060005.V316056.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 77 Victoria Road Care Home DS0000060005.V316056.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection 77 Victoria Road Care Home DS0000060005.V316056.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Thorough assessments and Terms and Conditions ensure that residents are confident that their needs may be met in the home. EVIDENCE: Resident’s case tracked had comprehensive pre- admission assessments completed, which demonstrated that the resident and their family had been consulted. There were copies of Terms and Condition of residence on file. 77 Victoria Road Care Home DS0000060005.V316056.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff do not always have the information required to ensure that all resident needs are met. Residents are treated with dignity and respect EVIDENCE: Residents spoken to were complimentary concerning the care received and appeared clean and well groomed. Relationships between residents and staff were observed to be relaxed and friendly and assistance was provided in a sensitive manner when required. Four residents were chosen in order that their experience in the home could be assessed. This involved looking at their records and talking to them and the staff concerning the care provided. Two residents were chosen from the dementia unit, one from the older persons area and one from the mental illness category. A comprehensive system of assessment is in place and resident’s needs are identified in conjunction with them and their relatives. Records of lifestyle, 77 Victoria Road Care Home DS0000060005.V316056.R01.S.doc Version 5.2 Page 10 hobbies and interests as well as choices concerning daily routine were recorded. Care plans following these assessments however remain insufficient to guide unfamiliar staff concerning individual needs. For example: • Residents with a diagnosis of dementia or mental illness did not have care plans in place to address their mental health needs. Instruction such as “ Contact the Community Psychiatric Nurse” was made, but there was no instruction as to how presenting moods and behaviours could be addressed by staff or coping strategies for behavioural problems. Residents with a diagnosis of diabetes mellitus had no care plans to instruct staff concerning fluctuations in blood glucose levels. • Statements such as “assist with daily wash” were made with no explanation concerning what assistance was required. • One resident’s daily record stated that she was being visited by the Community Nurse concerning a pressure ulcer on her bottom, but there was no care plan in place for this despite references to staff changing the dressing in the daily statement. Insufficient care plans was a requirement at previous inspections and this remains outstanding. Systems for the ordering, storing, administration and disposal of medication were seen and found to be satisfactory. Advice was given that the temperature should be monitored in the medicine storage areas to ensure that medications are stored below the recommended 25 degrees Celsius. • 77 Victoria Road Care Home DS0000060005.V316056.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social Activities and meals are both well managed, creative and provide daily interest and variation for people living in the home. EVIDENCE: Residents monitored had records of their life history and records of their preferred hobbies and interests as well as records of their participation in social activities. An activities co-ordinator is employed and she organises a wide range of activities in the home. For example a BINGO session was enjoyed during the morning of the inspection, followed by the mobile shop and then manicures. One resident stated that he had enjoyed a trip to Mabelthorpe in the summer and looked forward to future outings. Residents were putting their names down for an organised Christmas outing. Outside entertainers visit each month to provide further interest. The activities co-ordinator tries to spend individual time with the residents in the dementia unit and is planning to attend a course in the near future to help her meet the specialist needs of this group. 77 Victoria Road Care Home DS0000060005.V316056.R01.S.doc Version 5.2 Page 12 Menus seen demonstrated that a varied nutritious diet is provided. Residents spoken to complimented the cook on the standard of food provided. Visitors are welcome at any time and a notice invited them to help themselves to tea and coffee. One gentleman had been out with relatives on the day prior to the inspection. 77 Victoria Road Care Home DS0000060005.V316056.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents may be confident that their concerns will be addressed and that they will be protected from abuse. EVIDENCE: There have been no complaints received by the Commission for Social Care Inspection and one received by the home from care management was investigated and found to be unsubstantiated. Copies of the complaints procedure are on display in the home and may also be found in the Terms and Conditions of residence. A large folder of compliments and “thank you” cards and letters was available from relatives whose family had been cared for in the home. Staff training records demonstrated that all staff receive training in the Protection of Vulnerable Adults from abuse, and staff spoken to confirmed this. All staff have Criminal Records Bureau checks in place prior to employment. 77 Victoria Road Care Home DS0000060005.V316056.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 23, 24, 25 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in homely surroundings, which are well maintained and clean, but no environmental adaptations have been provided to enable residents with a diagnosis of dementia, to maintain their independence. EVIDENCE: A limited tour of the environment demonstrated that the home was maintained to satisfactory standards. Light, airy communal rooms are available throughout the home and pleasant gardens are available in good weather. Resident’s rooms showed evidence of personalisation with small items of furniture, pictures and ornaments on display. All areas of the home were warm and comfortable. Areas seen were clean and hygienic. 77 Victoria Road Care Home DS0000060005.V316056.R01.S.doc Version 5.2 Page 15 Residents with a diagnosis of dementia are cared for in a separate unit within the home, although they have free access to the rest of the home. There are no environmental adaptations in place to maximise the independence and reduce the confusion experienced by this group. Advice was given concerning this. 77 Victoria Road Care Home DS0000060005.V316056.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Procedures for the recruitment of staff provide safeguards necessary to offer protection to the people living in the home. The company has a commitment to staff training but insufficient staff are provided to meet the needs of all resident groups. EVIDENCE: Duty rotas demonstrate that there is one team leader plus six carers in the morning, one team leader and five carers on the late shift and one team leader and two carers at night. Staff allocation within the home results in the dementia unit being unattended at certain times of the day if staff are called to attend to residents in other units. This leaves this very vulnerable group unsupervised at times and at risk from harm as they have free access to other areas of the home and to each others rooms. A large number of falls have been reported since the last inspection, which would also indicate a lack of supervision. One gentleman from this unit is reported as being very unsettled at night and requiring one to one supervision in order to keep him safe. Staff report that this is not provided if they are called to attend to other residents, and he is left unattended in the main lounge area of the home. Dedicated staff for this area was a requirement at the last inspection and remains outstanding. A selection of staff files seen, demonstrated that thorough recruitment procedures are in place in order to protect residents from potential harm. 77 Victoria Road Care Home DS0000060005.V316056.R01.S.doc Version 5.2 Page 17 These include the taking up of references and Criminal Records Bureau checks. An equal opportunities policy is in place, and staff from a variety of different ethnic backgrounds,ages and both sexes are employed. The company have a commitment to training and employ a training manager. A training matrix is available to monitor statutory training and updates. Thirty of the forty- four staff currently hold or are working towards a National Vocational Qualification in care, which gives them a basic understanding of resident care needs. A four- day induction is provided for all new staff, during which basic policies and procedures are learnt along with an introduction to more in depth information. Staff records demonstrated that this training had been provided and staff spoken to confirmed this. Staff are deployed throughout the home and not all of the staff working in the dementia unit have received training in this area. 77 Victoria Road Care Home DS0000060005.V316056.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 35, 36 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Registered Manager ensures that the home is run efficiently, in a way that considers the interests of the residents. The safety of residents with a diagnosis of dementia is not always maintained. EVIDENCE: The Registered Manager has several years experience in caring for this resident group and relationships between her and residents and staff were observed to be relaxed and friendly. As stated above, staffing levels do not allow for the best interests of the residents to be considered, although resident meetings and surveys are conducted to ascertain their views. Results of these surveys were on display 77 Victoria Road Care Home DS0000060005.V316056.R01.S.doc Version 5.2 Page 19 throughout the home and minutes of resident meetings were seen on the various notice boards. The company has a commitment to quality assurance and all areas of the home are audited on a monthly basis. The high number of falls has been identified and all such incidents have to be reported to head office for collation and review. A system of regular supervision and appraisal of staff is in place and staff confirmed this in discussion. Good systems are in place to monitor the administration of resident’s pocket money accounts. Records of the testing of fire alarms, emergency lighting and hot water systems were seen and found to be satisfactory. Staff fire drills are held and the registered Manager confirmed that action required following the last visit by the Fire Officer had been taken. The kitchenette area in the dementia unit has been made safe following the last inspection but as these residents have free and sometimes unsupervised access to the entire home, other hazardous areas may present a risk to this specialist group. A requirement was made in this respect. 77 Victoria Road Care Home DS0000060005.V316056.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 1 3 3 3 3 STAFFING Standard No Score 27 1 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X 3 3 X 1 77 Victoria Road Care Home DS0000060005.V316056.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement The Registered Persons must ensure that sufficient detail is recorded in the care plans that directs and instructs staff in the appropriate care provision required. (Previous timeframe of 30/9/04 and 1/1/05 and 1/9/05 and 01/01/06 not met) Timescale for action 24/11/06 2 OP8 12(1) a 3. OP27 18 (1) a Residents with a diagnosis of 01/12/06 dementia or mental health problems must have their mental as well as physical needs met in the home. Staffing levels must be sufficient 24/11/06 to ensure that a member of staff is present in the dementia unit at all times in order to maintain the safety of this resident group. (Previous timeframe of 01/01/06 not met) Suitable environmental adaptations must be provided to meet the specialist needs of those residents cared for in the dementia unit. Attention must be given to the security of the dementia unit in DS0000060005.V316056.R01.S.doc 4 OP22 23(1) a 01/01/07 5 OP38 13(4) a 24/11/06 77 Victoria Road Care Home Version 5.2 Page 22 order to prevent residents being harmed by wandering unattended in the rest of the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 77 Victoria Road Care Home DS0000060005.V316056.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 77 Victoria Road Care Home DS0000060005.V316056.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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